Health inspection·February 4, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm following dates: 1/6/25, 1/7/25, 1/8/25, 1/10/25, 1/13/25, 1/15/25, 1/17/25, 1/20/25, 1/22/25, 1/24/25, 1/27/25, 1/29/25, and 1/31/25. R7's progress notes document a referral to dialysis on 12/6/24 with subsequent first-time dialysis on 12/18/24, followed by orders for dialysis three times a week starting on 12/25/24. Residents Affected - Few R7's care plan does not document dialysis services for R7. On 2/3/25 at 1:30PM, V4 Social Service Director/Care Plan Coordinator stated that currently there is no Minimum Data Set/Care Plan Coordinator. V4 stated Dialysis for (R7) and the intervention of (non-slip material) in R4's chair to keep her from falling out of the wheel chair both should have been documented and it just didn't get done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess for elopement risk, document the rational for application of an elopement notification bracelet, and re-apply an elopement notification bracelet after readmission from the hospital for one (R6) of three residents reviewed for elopement from a total sample list of ten residents reviewed. Residents Affected - Few Findings include: The facility Elopement and Wandering Residents Policy revised 5/6/2024 documents that the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazard and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. R6's current medical diagnosis record dated 2/4/24 documents R6 has Vascular Dementia, Repeated Falls, Panic Disorder, Depression and Parkinson's Disease. R6's Minimum Data Set (MDS) assessment, dated 11/25/24, documents R6 is severely cognitively impaired. R6's admission Elopement assessment dated [DATE], documents R6 is not an elopement risk. R6's Nurse Progress Note dated 11/25/24, documents an elopement management bracelet was placed on R6's left ankle due to high elopement risk. R6's current care plan documents R6 is an elopement risk on 11/26/24, and R6 has an elopement management bracelet on left ankle. R6's medical record does not contain an elopement assessment or documentation of why an elopement management bracelet was applied to R6 on 11/25/24. On 2/3/25 at 1:30 PM, V4 Social Service Director (SSD) stated an elopement management bracelet was placed on R6 because R6 was telling staff she was going to leave building to go across the street to visit her boyfriend and take him shopping. V4 stated R6 will go to the door and try to leave but is able to be redirected. On 2/3/25 at 1:00 PM, V4 SSD stated that she thought nursing was completing the elopement assessments; however, she learned today that it is her job to complete all elopement assessments. V4 SSD then confirmed that R6's medical record does not contain documentation of an elopement assessment or progress note documenting the reason for placement of the elopement management bracelet on 11/25/24. On 2/3/25 at 1:30 PM, V8 Licensed Practical Nurse confirmed R6 does not have an elopement management bracelet in place. On 2/3/25 at 1:05PM, V4 SSD confirmed that R6 does not have an elopement assessment from readmission to facility on 1/30/25. Additionally, V4 SSD confirmed R6 does not have an elopement management bracelet in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loft Rehab & Nursing of Normal 510 Broadway Normal, IL 61761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm On 2/3/25 at 1:00 PM, V4 Social Services Director (SSD) stated a resident should have an elopement assessment completed on readmission to the facility. V4 SSD stated that R6 went to the hospital recently and was re-admitted to the facility. V4 stated that she was not aware that a re-admission elopement assessment wasn't completed nor was an elopement management bracelet reapplied at this time. V4 SSD further stated R6 does try and exit the building and needs an elopement management bracelet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145031 If continuation sheet Page 4 of 4